Curbing antimicrobial resistance in post‐COVID Africa: Challenges, actions and recommendations

Abstract Background Antimicrobial self‐medication and use have significantly increased in the COVID‐19 era—increasing antibiotic consumption and resulting in a high prevalence of antimicrobial resistance in Africa (AMR). We conducted a narrative review to investigate challenges associated with curbing AMR in a post‐COVID‐19 setting in Africa, suggesting practical measures applicable for policy‐informed implementation. Method A narrative review was performed to pinpoint AMR challenges and actions on the African continent. A comprehensive search was conducted in the scientific databases that include PubMed, PubMed Central and Google Scholar using predetermined search terms. Results The emergence of the COVID‐19 outbreak has added to the challenges of tackling AMR on the continent, which has jeopardized AMR interventions' hard‐won gains. Identified challenges have been Health systems disruption, Irrational Antimicrobial Use, Weak Antimicrobials Regulatory Ecosystem, Inefficient Population Infection Prevention, and Control Practices, Inadequate access to Health Services and data challenge on AMR surveillance. Conclusion The COVID‐19 pandemic fueled AMR in Africa. There is a need for AMR control post‐COVID, such as measures for ongoing antimicrobial stewardship and good infection control practices. Further, curbing AMR requires rigorous regulatory enforcement and efficient AMR Surveillance. There should be a body to raise AMR awareness among the population. Research, Innovation and Technology could play an essential role supported by capacity building and global partnership.

Infection Prevention, and Control Practices, Inadequate access to Health Services and data challenge on AMR surveillance.

Conclusion:
The COVID-19 pandemic fueled AMR in Africa. There is a need for AMR control post-COVID, such as measures for ongoing antimicrobial stewardship and good infection control practices. Further, curbing AMR requires rigorous regulatory enforcement and efficient AMR Surveillance. There should be a body to raise AMR awareness among the population. Research, Innovation and Technology could play an essential role supported by capacity building and global partnership. impacted Africa, with the vulnerable population bearing the brunt of the burden. 1 The fear of mortality due to the pandemic has been high, 2 while health care services focus on the pandemic. The availability of staff and accessible quality medications play an essential role in responding to the outbreak and are considered critical bodies of health infrastructure. 3 On the contrary, the understaffing and the lack of drug supply pose a challenge to the health systems, thus impelling poor health outcomes. 3 As African health systems were inadequately prepared to respond to the pandemic, the adverse effects on health services have been numerous. There was a lack of accessible quality health care services, compounded by the COVID-19 surge and paucity of equipment such as testing material. Similarly, the protective policies devised to curb the pandemic have decreased the seeking for health care, and some already-scheduled services have been canceled or missed. 4 These factors have contributed to self-medication and inappropriate antimicrobial use. 5 Self-medication is associated with the emergence of antimicrobial resistance (AMR).
During the COVID-19 pandemic, self-medication has extensively increased in Africa. 6,7 Self-medicated drugs have included but were not limited to antibiotics such as Metronidazole, Amoxicillin, Azithromycin, Ciprofloxacin, and antimalarial including Hydroxychloroquine and Chloroquine. 6 An increased antibiotics self-medication in uncomplicated illnesses in the population in resource-constrained Africa is a growing issue, leading to a high prevalence of AMR.
AMR has been one of humanity's most significant global health threats today. It is a public health problem that transcends continents and national borders and is rapidly growing, as seen with the sixfold increase in resistance rates since 2017. 8 For instance, antimicrobialresistant bacterial strains could lead to untreatable infections and cause 10 million deaths each year by 2050. 9 Understanding AMR in Africa post-COVID-19 can prevent its extension and avoidable deaths.
However, little is known about AMR in the post-COVID-19 context in Africa. There is a need to conduct research to provide strategies and policy responses for a resilient recovery post-COVID, essential in driving a systems approach to ensuring population safety. 10 This narrative review explores challenges related to curbing AMR in a post-COVID-19 setting in Africa and provides recommendations for practical measures useful for policy-informed implementation.

| METHOD
We conducted a narrative review of data sources to identify AMR challenges and actions in African countries. A comprehensive search on PubMed, PubMed Central and Google Scholar was conducted using predetermined search terms. The inclusion criteria were data sources, that is, relevant articles about AMR interventions and associated successes and challenges in African countries and were published in English. References of the data sources were also reviewed to identify relevant information. Supporting Information Data were also gathered from country reports, commentaries, policy briefs and other reports. The collected articles were managed using Mendeley Reference Manager. The extracted data were discussed narratively to explore the aim of the study.

| Burden of AMR
The distribution of substandard and counterfeit antimicrobials has a significant contribution to the spread of AMR, particularly in Africa. 11 Before the COVID-19 outbreak, with over 700,000 deaths annually, 12 AMR was a pandemic, circumventing health care delivery globally, claiming 1.27 million deaths worldwide and the six leading resistant pathogens associated with over 92 million deaths as of 2019. 13 In Africa, the significant impact of AMR is becoming more apparent, with western sub-Saharan Africa having the highest all-age death rate of 27.3 deaths per 100,000. 13 This concern is compounded by a weak and fragmented public health system across the continent and a high burden of infectious diseases, with 62% of disability-adjusted life years (DALYs) in the African region attributable to infectious diseases. 14 With COVID-19 ruling most aspects of health care delivery globally, the effects of this phenomenon are gaining more impact. The rising and evolving public health concern is associated with increased morbidity and mortality. 15

| Global Action Plan (GAP) and implementation in Africa
Compounded by COVID-19, AMR can drive more people into poverty, jeopardize global health security, and obstruct progress toward the Sustainable Development Goals and universal health care. 16 Africa is already at a loss, with more than half of the world's poorest communities coupled with the high burden of infectious diseases. The design of the GAP on AMR is to align the optimal use of antimicrobials and to develop the knowledge and evidence base through research and surveillance. 17 This GAP provided a template for countries to create their AMR national action plans (NAPs). Using an incremental approach lays out the crucial steps that the various stakeholders should take to address AMR over the next 5−10 years. However, Africa is slow on the uptake in aligning with current international efforts to fight the increasing pandemic of AMR as few countries have AMR NAPs. Challenges that include a mix of insufficient local awareness, inadequate data and knowledge of AMR impact, and a lack of technical and financial resources for implementation and research and progress monitoring have stalled the action plans. 18,19 Implementing the NAPs is very cost-intensive, a luxury Africa cannot afford. For instance, it was estimated that the implementation of Zimbabwe's NAP would cost $44.6 million over 5 years from 2017. 20 Interestingly, some countries have even estimated double that amount for their implementation. The World Health Organization (WHO) insisted that African countries must raise health budget expenditures if they wish to enhance their people's health and meet international health targets. 21 AMR can escalate the cost of health care, and most African countries have failed to meet their Abuja Declaration commitments of setting aside 15% of their national budget for health. A governance framework is required to guide and support researchers and stakeholders in developing and assessing these NAPs. 22

| Challenges of AMR control in Africa
The emergence of the COVID-19 outbreak has elevated the stakes for AMR response. Health systems responses and public health priorities have evolved due to the pandemic, and this evolution has threatened the hard-won gains of AMR interventions (Table 1).

| Health systems disruption
While most African health systems adopt a hierarchical design in health care provision, lower-tier levels with community proximity are underfunded and underutilised, limiting the health system's capacity. The weak health system, inadequate health care delivery and shortages of supply of essential medicines in public facilities limit the ability and capacity to tackle AMR. 23 While the development of AMR has been attributed to the increasing antimicrobial utilization, poor governance, corruption, and lack of adequate control due to fragmented health systems management are important drivers of the epidemic. A lapse in oversight and enforcement of policies and regulations relating to antimicrobials distribution furthers the plight. 24 The lack of specific funding sources, especially budgetary allocation, is a challenge as the only official allocation for the federal budget for AMR activities was found in Nigeria. 24 The COVID-19 pandemic has had a significant impact on health systems. Effects range from the deprioritisation of AMR presented as funding challenges for AMR partnerships and bias in the collection of AMR data with admissions and procedures influenced by the pandemic, health workforce shortage, workforce and health system resources in the pandemic response. 5 COVID-19 has had a sweeping effect on new and existing AMR partnerships and stalled the oversight and accountability of AMR interventions. 25

| Irrational antimicrobial use
Human behavior has been the primary driver of AMR, and the problem of nonprescription antimicrobial consumption is widespread in Africa.
Widespread and indiscriminate empirical use of antibiotics has been a significant risk factor for AMR development in Africa. AMR emergence is fostered in environments where it is common practice to buy antibiotics over the counter. In developing environments, excessive use is attributed to ease of access and perception of antibiotics as "wonder drugs," while amongst the affluent, inappropriate indication plays an important role. 26 In Sub-Saharan Africa, over 70% of antibiotics are supplied without prescriptions. 27 T A B L E 1 Challenges of AMR control in Africa Around 70% of COVID-19 inpatient or outpatient settings received antimicrobials primarily for empiric use. 28 It has been discovered that broad-spectrum antibiotics were mainly recommended for mild to moderate COVID-19 management, which violates WHO guidelines and significantly reduces selection pressure. 29 Without much evidence to support its use, Azithromycin is common in treating COVID-19 patients globally, including in Africa. 30 The high workload and stress worsened by the COVID-19 pandemic give little room for adequate therapy and medication review.

| Weak antimicrobials regulatory ecosystem
In Africa, where low and middle-income countries predominate, antimicrobial purchasing is less regulated. 29 Over-the-counter antibiotics procurement is common in Africa, as 100% of antibiotics can be procured without prescriptions in some African countries. 27 Antimicrobials can be procured on the roadside, in small shops and stores, dispensed by auxiliary nurses in communities, and irrationally dispensed by pharmacies who put economic interest over the public good. 31

| AMR awareness
In 2015, the GAP on AMR adopted by WHO listed improving awareness through effective communication, education, and training as its first objective. 40 40 AMR information and infectious diseases management education dissemination in local language harnessing primary health centers optimizes regional reach.  2. Encouraging Antimicrobial stewardship evidence-based updates on practice guidelines of health professionals, routine and independent review of stewardship practices, and collaboration with medical and pharmaceutical professional bodies.

| Efficient AMR surveillance
3. Improving access and quality of care by optimizing primary health care.
4. Improved AMR surveillance with a focus on antimicrobial utilization and changes in epidemiology. Collaboration to improve the quality of surveillance systems.
5. Assessment of progress and updates on National Action Plans for AMR. Accountability mechanisms and change management system frameworks for AMR policies and interventions.
6. Adequate funding, support and autonomy for regulatory enforcement procedures and the development of validated systems, practices and policies for quality systems. Unauthorized access to antimicrobials should be discouraged-enforcement of scope of practice of patent drug vendors.
7. Improving laboratory capacity and data collection systems.
8. Implementation of research with collaboration and community engagement at the core and innovation with technology for quality health.
9. AMR frameworks must strengthen the competence and capacity of the health workforce for health systems' resilience. Undergraduate training must incorporate AMR training into undergraduate studies to promote stewardship. 10. Global dialogues and advocacy. Collaboration with advocacy groups to promote continuity of intervention and optimize reach.
SHOMUYIWA ET AL. | 5 of 9 data, analysis and distribution inform the decision making on a national and international scale. 30 COVID-19 and its associated changes, such as increased antimicrobial use, underline the importance of optimizing AMR surveillance to monitor AMR trends with global health changes. 25 AMR data management should assess biases in current analyses of AMR surveillance data.
AMR surveillance in the wake of irrational antibiotic use in the context of the COVID-19 pandemic is essential to adapt to changes in AMR epidemiology. 42 Focus on changes in antimicrobial utilization, diagnostics and resistance reporting is vital. A study in Ethiopia demonstrated that the development of standard AMR surveillance is attainable with solid leadership and stakeholder engagement. 45 Collaboration of African countries with GLASS to improve the quality of surveillance systems makes for reliable data of global capacity. The active dissemination of surveillance data amongst policymakers and stakeholders is vital to drive their use as evidence in policymakingthese work to provide relevant and scientifically valid epidemiological data to base decisions and policies on AMR.

| Implementation of infection prevention policies
With the COVID-19 management, health systems triggered infection prevention policies by appropriately isolating cases and public health practices, including personal protection. 37

ACKNOWLEDGMENTS
Authors are grateful to reviewers for their insightful comments.